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Epilepsy Management and Epilepsy Surgery

Epilepsy Management and Epilepsy Surgery. Melissa A. Carran, M.D. Assistant Professor, Division of Neurology Cooper University Hospital/UMDNJ. Introduction. Current state of drug therapies Alternative therapies Epilepsy Surgery cases. The Ketogenic Diet.

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Epilepsy Management and Epilepsy Surgery

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  1. Epilepsy Management and Epilepsy Surgery Melissa A. Carran, M.D. Assistant Professor, Division of Neurology Cooper University Hospital/UMDNJ

  2. Introduction • Current state of drug therapies • Alternative therapies • Epilepsy Surgery cases

  3. The Ketogenic Diet • The ketogenic diet was first used as a treatment in 1921 • .Mimics the effects of fasting, using fat as major energy source leading to the production of ketone bodies. It is effective for myoclonic, focal and temporal lobe epilepsy. • The exact mode of action still unknown

  4. Monitoring • Regular testing of urinary ketone levels: ketone level = 3.9- 7.8mmol/1. 3-4x/d • If an initial starvation period is not instigated prior to the commencement of the diet then testing for ketones should not be carried out until the diet has been followed for at least 10 days. • Dehydration 1L/ day

  5. 4g fat to each 1g protein and carbohydrate combined; in children under the age of 18 months a ratio of 3:1 • Calculation of daily amounts. If the patient's weight is Wkg then: • Energy content (kcal) = 75 x W • 4:1 ratio: • Fat content (g) = 7.5 x W • Protein content (g) = W • Carbohydrate content (g) = 0.875 x W

  6. Johns Hopkins Study (Kinsman et. Al 1992) • 58 children <10y/o • most Lennox Gastaut • Improvement usually in 1st 2 weeks • over 2 years: 38% had 1/2 seizure freq.; 29% seizure free • diet tappered after 2 years

  7. Side effects • hyperlipidemia • hyperuricemia • hypercalciuria • hypoglycemia • growth retardation

  8. Epilepsy Surgery in Children • Predicting medical intractability • 125,000 new cases/yr • 30% < 18y/o; most birth - 2y/o

  9. Berg et. Al, Neurology 2001 • 613 Children (5.3y/o median) • intractable= failed 2 or more drugs. One sz/month over 18 mos. • Symptomatic Generalized epilepsy, high initial sz frequency, focal EEG • remissions 14% after 1.5-3 years

  10. Temporal lobe epilepsy • (Mohamed et al. Neurology 6/01) • 17 children/ 17 adolescents (12y/o) • MRI hipp. Sclerosis on side of Sz onset • 78% seizure free after ATL

  11. Loading dose 15-20mg/kg Maintenance: 200-300 mg/d (qd or bid) T 1/2 7-42 hrs Saturation Kinetics Level 10-20 mcg/ml Unbound 10% Side effects: nystagmus, ataxia, dizziness, hirsutism, gingival hyperplasia, peripheral neuropathy, oseomalacia, folate deficiency, cerebellar atrophy, hepatitis, hypersensitvity syndrome, local rxn. Phenytoin (Dilantin)

  12. Initiate: 100-200mg qhs x 5-7 days; add 200mg/day Maintenance: 400-2400mg/d T1/2= 25-60h (initial),12-17h (chronic) Hepatic autoinduction Side effects: drowsiness, dizziness, diplopa, ataxia, visual blurring, osteoporosis, peripheral neuropathy, water retention, hyponatremia Carbamazepine (Tegretol)

  13. Partial seizures 1200-2400 mg/day Rapid hepatic reduction Metabolites renal elim. No drug interactions Side effects: Oral contraceptive reduction? Bone loss? Hyponatremia Oxcarbazepine (Trileptal)

  14. Phenobarbitol Side effects: sedation, dizziness mood change, insomnia, hyperkinesis, cognitive dysfunction, osteoporosis, Dupuytren’s contracture, frozen shoulder, reduced libido, rash, hepatotoxicity 10-20 mg/kg loading 60-240 mg/day 25% renal/65%hepatic T 1/2= 50-140 hr Primidone (mysoline)

  15. Gabapentin (Neurontin) Side effects: somnolence, dizziness, ataxia, edema Initiate 300mg/day, bid, then tid Maintenance 900- 4,800 mg/d 98%renal excretion Not protein bound

  16. Lyrica • Pregabalin is a 3-substituted analogue of gamma-amino butyric acid (GABA) and a compound related to Pfizer's hugely successful antiepileptic drug gabapentin. (Source: ABPI)

  17. Partial and Generalized Sz and Absence 5-10 mg/kg/day (250-750mg) Depakote ER; 250mg more up to 2000mg (500) Depacon 60 min IV or <20mg/min Side effects: Hair loss, tremor, weight gain, thrombocytopenia, hepatiotoxicity, pancreatitis, Valproic Acid

  18. Levetiracetam (Keppra) Side effects: irritability, rare psychosis, somnolence, personality change Start 250mg bid, 500mg bid renal excretion Not protein bound

  19. Initial: 50mg increase/wk bid Maintenance: 200-600mg/day (bid) 70% renal excretion; dosage 1/2 in renal impairment Side effects: kidney stones (1.5%), somnolence, fatigue, psychomotor slowing, difficulty with concentration, confusion, paresthesias Topiramate (Topamax)

  20. Partial and Gen.Sz. Myoclonic Jerks; ?absences Renal elimination 400-800mg/day Saturation kinetics Side Effects: weight loss, oligohydrosis, CBC/LFT monitoring Zonisamide (Zonegran)

  21. Status Epilepticus • Consecutive seizures without return to consciousness • Seizure for 30 min. • High mortality • Subtle convulsive status

  22. Treatment of Status • R/O hypoglycemia • Lorazepam IV 0.1 mg/kg; 1-2mg/min. • Phenytoin 20mg/kg IV (50-150mg/min) • Addt’l 10 mg/kg phenytoin • Intubate: Phenobarbitol 20mg/kg IV • EEG monitoring: sodium pentobarbital 5-15mg/kg; 5mg/kg/hr; midazolam or propofol

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